Herbal Treatments

/by William Rassman, M.D./0 /,

Hi from Virginia Dr Rassman! I am 27 and am concerned about a receeding hairline I (and my friends) have noticed occuring right above my temples. The hair in this location has always been thin, but has become more pronounced in recent years. What can I do to retard and even reverse this thinning? I have read about Propecia, and they do not recommend it for receeding hairline. Currently I am taking Saw Palmetto (supposedly an herbal Propecia), a sustained-release B Vitamin and MSM (both which supposedly feed and thicken hair). What other treatments are available for receeding hairline, herbal, pharmaceutical, or other?

If you have been losing hair in the temples and only the temples, then you may have a condition called Triangular Alopecia. IF this is the case, then you need a diagnosis. As I have repeated many times, the hair throughout your head must be observed with high magnification. If the hair loss is only in the triangular temple area, then this diagnosis is probable.

Make an appointment with a good hair doctor and show them this answer. They will know what to do. Don’t rush to herbal or other over the counter remedies without knowing what is going on. Once you get a good diagnosis then you should address the cause or use a treatment that works with scientific proof or at least a reasonable certainty.

Nizoral Shampoo

/by William Rassman, M.D./8 /

Is Nizoral better than other shampoos and can it promote hair growth?

Nizoral 1% (Ketoconazole 1%) is sold as an over the counter anti-dandruff shampoo. Nizoral 2% (Ketoconazole 2%) shampoo has twice the strength of the over the counter shampoo. The active ingredient, Ketoconazole is said to act as a DHT blocker. While some people who use Nizoral may believe that it does control hair loss, there is no objective evidence that it is anything more than a good shampoo.

Shiny Forehead

/by William Rassman, M.D./0 /

Dear Dr Rassman,
I hope you are well! Thank you for your dedication to providing men with a source of advice and information. I for one greatly appreciate it, and I am sure hundreds (thousands) of others do also!

I have a question that does not relate directly to hair loss, but one that is associated with appearance.

I have a high forehead, my hair has moved back an inch and a half directly in front and two inches roughly on the sides, with thinning on top. I tend to cut my hair short, usually a one or two shaven look. I am comfortable with the way I look, although I wish (as the majority of bald men do) had more hair, I am hoping that I will see more of a fuller appearance in time, since I started using Propecia two months ago.

My question is regarding the shininess I get on my forehead. It is greasy, oily moisture that accumulates during the day, which I usually wipe away with a tissue. I feel that if I could reduce the amount of greasiness I get on my brow I would feel better about my appearance. As the hair is thinning at the front, it makes my head look very shiny, when the back and sides of my head are thick with hair. Is there any product, or dietary plan that you could kindly recommend that may reduce this shiny appearance? I have found it is not good for the skin, to keep wiping the grease away with a tissue, it causes spots, which is the last thing I need at 23, along with the baldness!

Thankyou kindly for your help with this question. I hope you don’t mind me asking questions that are not directly related to hair loss.

Kindest regards

I gave this question to hair restoration surgeon, dermatologist, and my collegue Dr. Robert Bernstein to answer. Here’s his response:

The easiest way to remove oil from the forehead is with alcohol swabs. If you are acne prone then Erycette and Cleocin Pledgettes are topical antibiotics for acne that come on an alcohol based pad. These can be carried in your pocket but require a doctor’s prescription!

Switching From Propecia to Proscar

/by William Rassman, M.D./0 /

I have taken Propecia for 4 plus years with some success. I’d like to take proscar but don’t know how to go about it. Could you help? thanks

Proscar is the same drug as Propecia, just in a higher dosage per tablet. Propecia contains 1 mg of finasteride per tablet, and Proscar contains 5 mg of finasteride per tablet. When Merck did their studies on hair loss, it was determined that 1mg of finasteride was just as effective as 5 mg or even 10 mg of finasteride, but that taking only 1/2 mg of finasteride was 20% less effective.

So the only ‘benefit’ to taking more than the recommended 1 mg of finasteride in each Propecia pill, is a higher chance of side effects. If you want to take Proscar because it is more cost effective, you can split the pill into fourths. Splitting into fifths is more difficult and you tend to lose some of the pill in the cutting process. The doctor who prescribed Propecia for you, can prescribe Proscar for you.

Journal Articles on Propecia (Finasteride)

/by William Rassman, M.D./0 /, ,

Two articles are summarized below which address the drug Finasteride (Proscar 5mg and Propecia 1mg).

These article are very technical and may not be good reading, but I have put them here as part of my effort to educate the readership. Both of these articles discuss what we have learned on preventing prostate cancer with finasteride (very important as most men who live long enough will develop prostate cancer) and the cost/benefits of taking finasteride over time. In medical circles, these are controversial articles in many ways. I have included the comments of one doctor in the hair restoration field. Dr. Bill Reed, states: “An oversight on the author’s part that would probably negate the need to reduce the price of finasteride is the enhanced quality of having more hair! With regard to the authors’ basic approach, it’s an awkward premise to attempt to attribute a monetary value to quality. For example, is the real quality and value of treating BPH (enlarged prostate) with finasteride [to produce a] better sleep and absence of urgency or the money saved from a TURP? I’ve always loved how a healthier prostate and more hair probably go together with this drug [How does one quantify this value?]”

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European Journal of Cancer. 2005 Jul 29; The article addresses the finasteride prostate cancer prevention trial (PCPT) and asks: What have we learned?

Author: Mellon JK., Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, United Kingdom.

In 2003, the first of two large NCI-sponsored prostate cancer chemoprevention trials was reported. The prostate cancer prevention trial (PCPT) demonstrated a 24.8% reduction in the prevalence of prostate cancer in men taking finasteride 5mg/d for 7years. However, despite the overall reduced risk of prostate cancer, men in the finasteride-treated arm of the study were more likely to develop high-grade disease. This article examines some of the controversies aroused by the PCPT and evaluates some of the arguments that have been advanced in an attempt to explain some of the unexpected outcomes of the study. In addition, some of the recent studies assessing the potential impact of an effective chemopreventive strategy on population mortality are reviewed. To conclude, there is some discussion of factors, which need to be openly discussed with male patients who might be considered for finasteride therapy.

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The American Journal of Medicine. 2005 Aug;118(8):850-7. The article addresses the lifetime implications and cost-effectiveness of using finasteride to prevent prostate cancer.

Author: Zeliadt SB, Etzioni RD, Penson DF, Thompson IM, Ramsey SD., Fred Hutchinson Cancer Research Center, Seattle, Wash.; Health Services Department, University of Washington School of Public Health and Community Medicine, Seattle, Wash.

PURPOSE: We estimate the lifetime implications of daily treatment with finasteride following the results of the Prostate Cancer Prevention Trial (PCPT). In this trial, prostate cancer prevalence was reduced by 25%; however, an increase in the number of high-grade tumors among the treatment group necessitates the long-term projection of the likely benefits and costs. METHODS: We use a Markov decision analysis model with data from the trial, the SEER program, and published literature. The model measures the cost per life-year and cost per quality-adjusted life-year (QALY) gained for a cohort of men age 55 years who initiate preventive treatment with finasteride. RESULTS: Finasteride is associated with a gain of 6 life-years per 1000 men treated at an incremental cost of $1,660,000 per life-year gained. The quality-adjusted analysis results in 46 QALYs gained per 1000 men treated at an incremental cost of $200,000 per QALY gained, due primarily to the favorable effects of finasteride on benign prostatic hyperplasia. Under the assumption that the increase in high-grade tumors observed among finasteride treated men is a pathologic artifact, the incremental costs are $290,000 per life-year gained and $130,000 per QALY gained. CONCLUSIONS: The cost burden associated with finasteride is substantial, while its survival benefit is small and only realized many years after initiating treatment. To achieve an incremental cost below $100,000 per QALY gained, the price of finasteride must be reduced by 50% from its current average wholesale price and finasteride must be shown to prevent high-grade as well as low-grade disease.

Zocor and Hair Loss

/by William Rassman, M.D./1 /

I have noticed that my hair is thinning though it still grows as fast as before. I have been taking Karvezide medication for high blood pressure and Zocor for high cholesterol this has started since the Zocor was increased to 40mlg a day.

Hair loss has been a reported side effect of Zocor. In many of the drugs on today’s market, it seems that hair loss is frequently cited as a possible side effect so I sometimes wonder if the language is not routinely put in to protect the drug companies.

Limit on Donor Area

/by William Rassman, M.D./0 /

I had two hair transplant procedures approx 5-6 years ago. Obviously back then it was done by the strip surgery and not the new technique that seems fabulous. Being that I already have a scar from those sessions, is there any reason why I would go with the newer technique that limits scarring or does it matter at this point?

Also, does there come a point in time where you can no longer continue to take from your donor area for future procedures? Does the new technique allow one to continue having more procedures in the future where the strip would not have allow such an option?

Once you had a strip procedure, it probably is good to continue that route. The FUE procedures you are referring to, do not allow you to make more hair. In fact, they may limit the available donor supply simply because the best area for donor hair is in the central area of the back of the head and FUE does not maximize this area for donor.

Scalp Discomfort from Finasteride?

/by William Rassman, M.D./0 /

I know MPB can cause itching and scalp discomfort in some….have you ever seen the same problem occur with taking Finasteride long term —perhaps via hormonal upregulation? Thank you

I am not familiar with itching as a common complaint with Propecia/Finasteride, however, any medication can cause skin complications. If you suspect that Propecia/Finasteride is causing itching or scalp discomfort, you can go off of the medications for one or two weeks. Any skin complication due to the drug will go away because Propecia is out of your system in a day or two and the skin turn-over in your body is usually under two weeks.

Revising Non-Transplant Scars

/by William Rassman, M.D./0 /,

Dr. Rassman,

This is a bit of a tangent. I had 3 surgeries with you folks between 97 and 2000, and I continue to be pleased with the results. It appears it will be quite some time before I need more work done. When I researched different groups, you folks stood head and shoulders above the rest in terms of professionalism and especially how much research you had done. It was clear you were at least as interested in advancing the art as being successful from the business end.

Thus I am interested in your opinion on scar revision. I have two 6-7 inch scars – one on my elbow from nerve transposition surgery, another one that is horseshoe shaped above my armpit from reattaching a torn pec from a snowboarding mishap. Both scars spread kind of badly, such that at spots they are about as thick as my index finger. Apparently both those spots tend to be high tension, which causes the spreading. Both incisions were sutured with plain stitches or staples, not any interior stitches.

I’ve been doing web research on and off for several years, but I haven’t been able to convince myself that there is any group or technique that has a good chance of making a big improvement. What are your thoughts about the state of the art of scar revision? Perhaps this is a new area of study to apply your innovation. :)

When a person has stretched scars on many parts of their body, I often think of diseases that produce this problem. You should first be sure that you do not have any of these diseases such as Ehlers-Danlos Syndrome which is a connective tissue disorder. You are correct that some scars that come from wounds which are located in areas where the skin is stressed, can stretch in any person, even those without a connective tissue disorder. Plastic surgeons are often good at dealing with changing the way forces are applied to these stretched areas. One common procedure for managing scars is a process called a Z-plasty, where a linear scar is change to a Z type scar so that the forces do not oppose each other to stretch the scar. In the scalp, there are other factors far too complex for me to cover in a blog response here.

Minoxidil and Propecia Together

/by William Rassman, M.D./1 /

hey doc,

im 22 yrs old, experiencing receding hair line, and thinning of hair. i have been using propecia for the past few wks, and will continue using it for a while. should i also use rogaine? i wanted to know if it would benefit to use both or not. also, if i use rogaine, can i use a monoxydil subsititute, found at local grocery stores instead? will the cheaper generic product give the same intended effect as rogaine? please let me know.

thanks for your help.

Minoxidil is the generic form of Rogaine. Both are over the counter medications, sold at many places, you do not need a doctor’s prescription, like you do for Propecia.

I generally tell my patients to just take Propecia alone for at least 8 months to a year to be able to gauge its effectiveness. When you combine both Propecia and Rogaine from the beginning, you will not be able to tell if any effect is due to just one of the drugs or the combination, and you will be incurring the cost of both drugs for as long as you want the hair loss stopped or slowed down. If you find that Propecia by itself is effective and you are happy with the results, you have saved the cost of Rogaine for that period. If you are one of the few patients who do not get the desired results with Propecia, then you can stop taking the drug.

The two medications work differently. Minoxidil must be applied twice a day and it is messy. Propecia is a pill that should be taken every morning. Propecia attacks the hormone DHT that causes hair loss. Minoxidil was developed as an oral medication to treat high blood pressure and was found to have a side effect, which is the ability to grow hair in a small percentage of the population who took the drug. Minoxidil was then approved as a hair loss treatment in a topical solution called Rogaine. The topical Minoxidil can cause blood pressure drops and skin reactions, so you need to be careful taking it, and it does not work very well in the front of your head. Although Propecia does not impact regrowth in the frontal area most of the time, it will slow down or stop the loss in the front, particularly in young men.

Corrective Hair Transplant Questions

/by William Rassman, M.D./0 /

dr.rassman, hello. as a former patient i cannot give you enough praise for the corrective work you did on my scalp. my reason for writing is to ask a couple of questions. first, can my old punch style grafts, be redistributed to create a softer look? secondly, can my donor area which is according to you less than a 2 be used to soften and thicken my hairline. i still wear a hair system behind my frontal hairline about 2 inches back. i am afraid of my donor area being bald yet i want a softer look in front to disguise my system. i would stop wearing a hair system but i now have a medium sized bald spot on top and i don’t see a way of covering it up with a very small amount of donor hair left. dr. can you help me? maybe i can fly in to california and have a procedure done to correct my first 2 questions.

People who have depleted donor areas are very difficult to treat. Yes, you can redistribute hair from the old plugs that you received years ago. What you must do is define your problems and your goals, then prioritize them, then visit me or some other competent doctor who can address your problems. Without seeing how you look today, I can not reassess your situation with the new tools and techniques that are now available.

Correcting a Scalp Reduction

/by William Rassman, M.D./1 /,

I have undergone several transplants and scalp reductions over several years. Unfortunately the results have not been adequate and I have exhausted my donor area. I would like to consider cutting my hair short (to the scalp) or going with a shaved scalp. I am hesitant to do this because of scarring from scalp reductions and donor areas. Are there procedures to correct these imperfections or have I backed my self into a corner.

I doubt that you can shave your head without showing the obvious skin deformities that were caused by the various surgeries that you had done. Before packing it in, however, you should be seen by a good, honest, competent hair surgeon. Maybe your conclusions are not derived from knowing what can be done today.

Avodart (Dutasteride) Info

/by William Rassman, M.D./1 /

I have been using propecia almost 4 months and I didnt see any response yet .My hair got thinner I am 28 years old who has very thick hair and i have type 2 male pattern .My goal is to keep my hair , not to regrow . I have seen my hair receving from the frontal hair line little bit last couple weeks. Avadort has 50% better growth response than Propecia according to some research.Is it better for keeping the hair. And would you say i should keep using propecia and i started earlier than average patient , would it help me to keep my hair.when would htere be a drug that will stop the hair loss 99%.It doesn’t have to bring it back.And my family hair loss history is 3 A .

If you have been using Propecia for only 4 months, you should wait out a period of from 8-12 months before judging if it is effective at stopping the hair loss. Usually, people will see less fall out in the first 4 months. If after 12 months, there is still no cessation of the loss, then a visit with your doctor to talk about other options like Rogaine, Avodart, etc… may be appropriate. There is much new information out there that suggests, as you stated, that Avodart is more effective than Propecia. Avodart is not promoted as a hair loss prevention drug by the drug manufacturer, and the FDA has not ruled on its safety and effectiveness when used for hair loss. Safety is an issue and the FDA guidelines are generally worth following. The half life of Propecia is 4 hours which means that it will essentially be out of your system within a day or two, but Avodart may last for months, so if side effects occur, they will be with you for a long time. Get a good, open-minded doctor and establish rapport with him/her.

Scalp Colorings

/by William Rassman, M.D./3 /

I got the spray on hair from an infomercial. My baldness is just a small spot in the back, barely noticable. I must say, without looking at it closely, it is very hard to tell that it is not my hair. But my best friend picked it up and made fun of me. I understand that there are some scalp coloring agents that appear like hair. Are there other such things on the market?

There are a series of products that do this, with differing applications. Toppik is applied by shaking onto the scalp and surrounding hairs, binding to the existing hairs and making them thicker, and it also colors the scalp. Dermatch is more of a scalp colorant applied with a sponge, and you can find a product called ‘Tween Time (by Roux) at beauty supply stores, which is applied to the scalp with a lipstick like tube. These products come in shades to match your coloring and I have recommended them to patients before.

Accelerate Hair Growth After Transplantation

/by William Rassman, M.D./2 /,

I have recently seen a product called ‘Oat-Beta Glucan’ which a friend of mine had been recommended to be applied to his head after hair transplants. What do you know about things that make hair transplants grow better and faster, and how do they work?

In 1998, the Food and Drug Administration (FDA) issued its final rule allowing health claims to be made on the labels of foods containing soluble fiber from whole oats (oat bran, oat flour and rolled oats), noting that these foods, in conjunction with a diet low in saturated fat and cholesterol, may reduce the risk of heart disease. In order to qualify for the health claim, the whole oat-containing food must provide at least 0.75 grams of soluble fiber per serving. The soluble fiber in whole oats comprises a class of polysaccharides known as beta-D-glucans.

There are copper peptide solutions that are used after surgery which have claims to accelerate hair growth. I have not seen that result. I do use them on occasion because these products have some value in reducing the redness of wounds in people who have strong tendencies to develop redness when scratched. This persistent redness is caused by histamine release at the neurovascular junction points under the skin, at the site of a scratch. To get the benefit of reducing this redness in those prone to it, the solutions must be used immediately after the surgery and then twice a day for about a week. The classic person who has this problem has very fair skin, often red or blonde hair or has a history of persistent redness after scratches. You can test yourself by scratching you arm with your fingernail. If you have such a tendency, the scratch will turn red within a minute.

To summarize your exact question, there is no reference to hair stimulating effects of ‘Oat-Beta Glucan’ following a hair transplant in what I was able to find. When I was in Vietnam, many locals believed that putting cow dung on the hair stimulated hair growth. It is was also used to treat fresh war wounds when modern medicine was not available for those wounded in the war. Both ‘Oat-Beta Glucan’ and cow dung have about the same value for hair growth as much as I can tell.